| USDA - RUS |
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Title of Information Document |
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OMB No. |
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0572-0139 |
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| SUMMARY OF INFORMATION COLLECTION |
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7 CFR 1776 Household Water System Program |
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Date Prepared |
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Jan-11 |
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| INSTRUCTIONS: |
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> |
(f) TOTAL |
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(h) TOTAL |
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(k) TOTAL |
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| Use this form when a single information collection document involves multiple reporting and |
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> |
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= (e) Average |
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= (g) Average |
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= (j) Average |
| recordkeeping requirements. |
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> |
(d) TOTAL |
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(f) TOTAL |
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(i) TOTAL |
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| IDENTIFICATION OF REPORTING AND RECORDKEEPPING REQUIREMENTS |
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ANNUAL BURDEN |
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FORM |
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REPORTS |
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RECORDS |
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NO(s) |
NO. OF |
NO. OF |
TOTAL |
HOURS |
TOTAL |
NO. OF |
ANNUAL |
TOTAL |
| SECTION OF |
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(If "none" |
RESPON- |
RESPONSES |
ANNUAL |
PER |
HOURS |
RECORD- |
HOURS PER |
RECORD- |
| REGULATIONS |
DESCRIPTION |
so state) |
DENTS |
PER |
RESPONSES |
RESPONSE |
(Col. f & g) |
KEEPERS |
RECORD- |
KEEPING |
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RESPON- |
(Col. d & e) |
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KEEPER |
HOURS |
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DENT |
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(Col. i & j) |
| (a) |
(b) |
(c) |
(d) |
(e) |
(f) |
(g) |
(h) |
(i) |
(j) |
(k) |
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Items Cleared With This Package |
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| 7 CFR Part1776.7(c) |
Statement of Experience |
Written |
10 |
1 |
10 |
4.00 |
40.00 |
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| Application Guide |
Project Proposal |
Written |
10 |
1 |
10 |
72.00 |
720.00 |
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| 7 CFR Part 1776.7(b) |
Work Plan (scope of work) |
Written |
10 |
1 |
10 |
8.00 |
80.00 |
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| Application Guide |
Budget Justification |
Written |
10 |
1 |
10 |
4.00 |
40.00 |
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| 7 CFR Part 1776.7(d) |
Prior year Audit / Financial Statement |
Written |
10 |
1 |
10 |
0.25 |
2.50 |
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| 7 CFR Part 1776.9(d) |
Pro-forma Balance Sheet and Financial Statements |
Written |
10 |
1 |
10 |
5.00 |
50.00 |
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| Application Guide |
Organizational Documents-Evidence of Legal Existence and Authority |
Written |
10 |
1 |
10 |
0.50 |
5.00 |
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| Application Guide |
List of Directors and Officers |
Written |
10 |
1 |
10 |
0.25 |
2.50 |
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| Application Guide |
Evidence of Tax Exempt Status |
Written |
10 |
1 |
10 |
0.25 |
2.50 |
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| RD Instruction 1900-D |
Identify Employee Relationship |
Written |
10 |
1 |
10 |
1.00 |
10.00 |
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| 7 CFR Part 3018.110 & Application Guide |
Certification Regarding Lobbying |
Written |
10 |
1 |
10 |
0.08 |
0.80 |
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| 7 CFR Part 3017.335 & Application Guide |
Debarment and Suspension Information |
Written |
10 |
1 |
10 |
0.42 |
4.20 |
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| 7 CFR Part 3021.230 & Application Guide |
Drug-Free Workplace Requirements |
Written |
10 |
1 |
10 |
0.42 |
4.20 |
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| Executive Order 13166 |
Limited English Proficiency |
Written |
10 |
1 |
10 |
1.00 |
10.00 |
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| 7 CFR Part 1776.1 |
Grant Agreement |
Written |
5 |
1 |
5 |
3.00 |
15.00 |
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| 7 CFR Part 3019.26 and 7 CFR Part 3052 |
Annual Audit / Financial Statement |
Written |
5 |
1 |
5 |
0.25 |
1.25 |
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| 7 CFR Part 3019.25 |
Request written approval of workplan changes |
Written |
5 |
1 |
5 |
1.00 |
5.00 |
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| 7 CFR Part 3019.51 |
Project Performance Report |
Written |
5 |
4 |
20 |
2 |
40 |
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Total Items Cleared Under This Package |
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10 |
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175.00 |
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1,032.95 |
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Items Cleared Under Other Packages |
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| 7 CFR Part 1776.9(a)(1) |
Application for Federal Assistance |
SF-424 |
10 |
1 |
10 |
4 |
40.00 |
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(0348-0043 & |
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4040-0004) |
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| 7 CFR Part 1776.9(a)(2) |
Budget Information |
SF-424A |
10 |
1 |
10 |
1.5 |
15.00 |
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(0348-0044& |
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4040-0006) |
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| 7 CFR Part 1776.9(a)(3) |
Assurances - Non Construction Programs |
SF-424B |
10 |
1 |
10 |
1 |
5.00 |
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(0348-0040 & |
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4040-0007) |
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| 7 CFR Part 3018.110 & Application Guide |
Disclosure of Lobbying Activities |
SF-LLL |
5 |
1 |
5 |
0.25 |
1.25 |
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(0348-0038) |
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| Application Guide |
Equal Opportunity Agreement |
RD 400-1 |
5 |
1 |
5 |
0.25 |
1.25 |
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(0575-0018) |
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| Application Guide |
Assurance Agreement |
RD 400-4 |
5 |
1 |
5 |
0.25 |
1.25 |
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(0575-0018) |
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| 7 CFR Part 3019.22 |
Request for Advance or Reimbursement |
SF 270 |
5 |
12 |
60 |
1 |
60.00 |
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(0348-0004) |
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| 7 CFR Part 3019.52 |
Federal Financial Report |
SF 425 |
37 |
4 |
148 |
1.50 |
222.00 |
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(0348-0061) |
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